*bleep* holder – First Anaesthetic on-Call

So I have just come back from my first call as an anaesthetic doctor (or more specifically, an emergency medicine trainee rotating in anaesthetics who is holding the dreaded anaesthetic bleep very much reminiscent of a hand held grenade with the pin taken out. It may go off any second, heralding news which may be good or bad, usually bad).

So, I started the day taking a handover from my colleague who was the previous bleep holder. Or, I should rephrase that and tell you what actually happened. I waited for them to turn up to the operating theater for emergencies, and when they didn’t turn up after 20 minutes, I bleeped them. I found out they were in the middle of trying to help out a consultant with a dodgy arterial line for an elderly patient (who apparently at 92 had everything under the sun going wrong with her, and having managed to break her femur, was getting it surgically corrected), they rushed to meet me, handed me the bleep and a quick handover of the patients on the list (none!) and 2 patients that might require some analgesia maintenance sorting out later, and headed out the door. My first port of call was the consultant currently in the trauma theater dealing with the dodgy 92 year old. Old lady with CCF, AF on warfarin, small bilateral pleural effusions, past history of CVA (just last year) and a CABG 9 years back. She currently was using a frame to walk, and had tripped over an overturned edge of her carpet and ended up (long story short) on the operating table that evening. Anyway, the procedure went swimmingly, and she landed in recovery wihout any significant problems. My presence, though not directly helpful to the case, was atleast helpful in the sense that my consultant was able to grab a quick meal and some semblance of a hot beverage, and she mentioned she appreciated the chance to talk to someone. So far, so good, the call was going.

I was then bleeped about a potential appendix that was rumoured to have surfaced in A&E and the surgeons were contemplating taking it out. Young male, fit and well I was told. I took the opportunity to go round and see the patient myself, but as I was walking out of the recovery room, Cardiac arrest bleep goes off. In the heart centre (yes, ironic, isn’t it? I couldn’t make this up if I tried!) Apparently just a vasovagal syncopal episode though, as I ran down to the heart centre I saw the ITU registrar motioning me to relax as he seemed to have it under control.

Phew! On to the appendix…but first…ANOTHER CARDIAC ARREST BLEEP! Where is it? Second floor you say, oh the ward FURTHEST FROM WHERE I AM CURRENTLY STANDING? THANKS! I run to said ward, find CPR in full action on a what I understand is a 70 something year old gentleman found unresponsive on the ward (it is an orthopedic ward) and the rest of the history is a little late in coming, so CPR is in full progress, the ITU Reg enters almost at the same time as I do, he asks me if I have control of the airway, I reply in the negative as I am finding it difficult to bag mask ventilate. He chucks an I-gel towards me, which I insert successfully and ventilation is now adequate, as evidenced by the now rising saturations. CPR still ongoing, and there is now return of spontaneous circulation. He is intubated in the interim and post-resuscitative conversations/management are taking place (all this happens within the first 90 seconds of our arrival!) and someone then pipes up with the history (finally) that this patient is a known epileptic, admitted with multiple c-spine and other fractures, s/p corrective surgery for the spinal fractures 5 days back, was last seen alright 3-4 hours prior to being discovered unresponsive/in cardiopulmonary arrest. Based on the absence of pupillary reflexes, absence of any respiratory effort on the patient’s part, and cardiac function likely in response to the drugs given by us during the CPR, as well as the pre-morbid situation of the patient, it was the collective decision of the whole team involved to withdraw treatment. This was also agreed upon by the ITU consultant who we telephoned to ask for advice. The ITU reg offered to write up the notes as I took the tube out, and I went to see the appendix.

Very straightforward appendix – never had any anaesthetic, no family history of anaesthetic complications, last eaten/drunk something 11 hours back and that too vomitted up. Allergic to penicillin, otherwise fit and well young male with a slight language barrier, through which I discerned straightaway that he wasn’t happy about the surgery. He did not wish to proceed with the surgery for now. I stepped out of the room and let the surgical resident handle the situation. They would let me know if he still wanted the surgery. For now I would keep him on our list with an almost question mark. The staff in theaters would know what that code meant!

Bleeped again, this time from A&E RE an elderly female, Hmeatemesis with massive hemorrhage protocol in place, could we rush them into theaters for an urgent endoscopy +/- surgery? Her HB had dropped from a last known reading of 125 a few months prior to 49 on today’s blood gas. She already had a couple of IV lines secure, and the ED team had been excellent in pushing fluids, arranging blood and 2 units PRBC had already been given to her as well as 4 units of FFPs. I quickly pre-op assessed her, gave my consultant a quick phone call: he was happy to drive in (20 mins away) and assured me he would be ready and waiting by the time we got to the theaters. We did, and he was there, and it was an RSI, 4 more units of blood went into her, her last Hb was 98 and they found the bleeding point and treated it endoscopically, there was no need to open. Out into recovery where the ITU consultant also eyeballed her quickly, deemed to have no need for ITU support at that time and then moved to the ward after stable. He did ask me to give her the rest of the blood/FFPs booked for her, and afterwards send off clotting and FBC profile whenever transfusions over. Crisis averted (this took 2.5 minutes to write and around 2.5 hours to manage from start to finish, in which time I was bleeped 4 more times!)

One of those bleeps was from the surgical reg – appendix guy was agreeable and we would proceed for the surgery next. The consultant offered to do the RSI for this next one as well, I drew up the drugs for the case, and left to deal with the 2 pain patients from the handover (which seemed such a long time ago now!) and also deal with the 4 other bleeps that I had while we were dealing with PR bleed lady. 2 were urology cases apparently cystoscopies needed to be done for 2 elderly males, both with long term urinary catheters in place but unable to be taken out as the ballons werent deflating – eerily similar weird cases that were as much of an embarassment for the urology registrar as they were a hassle for the rest of the theater staff. Also while dealing with the bleeding lady, another consultant who was running the trauma list and who is now going home after his procedure has ended hands over 2 of his patients who are in recovery “shouldn’t be a problem but if there is just so you know about them” and walked out. I quickly scribble down their details so they don’t fall out of the back of my mind.

During my assessments of those 2 cystoscopies I got bleeped to remind me to do the bloods for the previous lady. I added it to my growing list of things to do.

I get called back to the theater because one of the other post-op patients in recovery (that the trauma consultant handed over) was being a bit…ummm…difficult. I quickly go see them. One of the other consultants prescribes some haloperidol. He is an elderly gentleman who has had a hip DHS, no prior known comorbids but slight cognitive impairment previously. But nothing as dramatic as how aggressive he was being right now. he was trying to get out of bed, he accused me of stealing his clothes and he accused the blushing nurse of having an affair with his wife, and he had quite a few choice words for how we were treating him. The halloperidol seemed to not do anything at all. It took all of our combined efforts (and a little bit of his analgesia) to calm him down and he went off into a deeply snoring snooze. Sigh. Phew.

9th bleep (or is it the 11th?) Urology registrar (sounding to be at the end of her thether, bless her) calling to tell me the first urology case cancelled as they were able to remove the catheter successfully, but the second case (similar) added to list, yet the consultant urologist was coming in to try to deal with it – should he fail, this was to be done cystoscopically so could we please keep the patient on our emergency list.

Another bleep – another story. A new bleeding patient, this time an esophagael variceal rupture potentially? Has not been booked on to the list but this is the theater staff calling to tell me there is a potential case – and to await further instructions. I swear I stared at the reciever of the phone to register my incredulity. At the end of the conversation I still wasn’t sure if there was or wasn’t a patient with a bleeding/hematemesis situation that needed to be urgently anaesthetized for their procedure. *DEEP BREATHS*

Another lap. appendix. Another x2 bleeps from pain relief point of view: something about a rectus sheath catheter that had dislodged, and another about someone who’s pain wasn’t being controlled despite adequate analgesia (problem was solved by a simple look at the drug chart which informed me that they WEREN’T in fact adequately analgesed!). 3 bleeps from various wards about cannulation difficulties. And finally, the last bleep of the day:

“Oh Hi there, it’s XYZ, coming to take handover – whereabouts are you?” I could have screamed in relief, but I managed to restrain myself till she got to the office where I handed over my bits and pieces. She was more senior than me, and asked how my first on call went, and then looked a more thorough look at me and said, “you know what? I know exactly how it must have gone – go home and get some rest. See you tomorrow!” Uncanny how she could discern from my expression and my hair and the overall dishevelled look and the stains on my OR shoes exactly how my first on call shift as an anaesthetic SHO went.

Just as I was stepping out of the office, I heard the bleep go off. And I was reminded of my own favourite pearl of wisdom: There is nothing worse than the sound of a bleep going off. And there is nothing better than realizing that it is someone else’s bleep that has gone off. I was smiling as I exited the office, and the hospital.

My PLAB experience (a VERY long time coming!)

Very recently, I was asked by one of my friends if I could share my experience about the PLAB exams, as guidance for prospective candidates. Having taken the exams quite a while back (2014!) I found it hard to address the issue, so they sent me a questionnaire to make things easier to explain to someone not very familiar with the way forward when contemplating taking the PLAB exams. I am sharing the whole Q&A session here (with a few minor adjustments/deletions with the author’s permission). Thank you @Sadaf Taymor (http://sidtay.blogspot.co.uk) for the opportunity to express myself and to share an important experience with everyone!

The curious case of PLAB (09/10/2017)

What is the PLAB exam and how does it help in initiating a medical career in UK?
There are many routes of entry into the UK for doctors who wish to train here. The easiest and most common one is to take the PLAB  (or Professional and Linguistics Assessment Board) exam and become GMC certified. Let me tell you a bit about this – basically any country that you work in has their own authority that confirms that you are good to practice in that country. For Pakistan, that authority is the Pakistan Medical and Dental Council, for the UK it is the General Medical council. Passing BOTH PLAB 1&2 gets you the license for the GMC to practice. After you get those out of the way and are certified then you are basically allowed to practice in the UK. That’s what people usually do.
The PLAB exams are the basic, entrance-level exams. You could potentially also get GMC certified by taking any of the more advanced membership exams for any of the Royal Colleges (but more about that at a later juncture – let’s keep this simple!)
The bottom line is you can not practice medicine in the UK without being GMC certified, and the easiest and most common route of entry to get that is to take the PLAB exams.
What kind of a format does this exam follow and what time limit does the candidate have for the exam
The PLAB has 2 parts – both are compulsory to pass individually. The first part is theoretical, and is based on the multiple choice questions format (or should I say, the single best answer format). You are given three hours to answer 200 questions. I have often heard people lament that the time is not enough, but I think it is doable. It may be difficult if you are not used to such a format, but in this field, better get used to this format, because later exams are also going to be in the same manner, same time frame (possibly even worse!)
The second part is interactive and consists of multiple stations. It is OSCE-based format, where each candidate rotates in 14 stations, each station assessing a different skill. Examples of such interactive sessions include taking a proper history, examining certain system, counselling a patient about something, and so on.
You can attempt the PLAB 1 as many times as you wish. Once you pass it, you have three years to pass the second part, failing which you will have to take the PLAB 1 again. You have 4 maximum attempts to take the PLAB 2.
Does the test have a certain validity?
Once you pass both parts of the exam and are GMC certified, you do not have to retake it again. You just have to keep up to date your assessments and your competence and you get re-validated automatically every 5 years.
 Any specific tips on cracking the test?
For the first part, I would advise go back to your roots, back to the basics. The whole syllabus is available on the GMC/PLAB websites. Try to practice as many questions as you can, get your tempo going, get used to this format before you take the exam. 2-3 months of prep should be enough.
For the second part, it can only be taken in the UK so make sure you have everything sorted before you travel for the exam. There are course available which guide and prepare and help practice the various stations that may come in the exam. These preparatory courses are much recommended before you take the PLAB 2 (if you have never worked in the UK or similar circumstances before).

Another day, another training…

Attended another training/teaching day sponsored/arranged by the deanery – was a very, VERY useful and informative day – and though it dragged on for hours, it was very interesting and explained quite a few things that I had not known previously – gist of the major salient points of each of the talks are listed below – may expand on 1 or more of these topics in the near future – so inspiring!

There were 4 speakers

PUBLIC HEALTH PROMOTION – how to explore facets of public health while in ED, because most people interact with someone in the ED, and that may be the only point of medical contact they have had up until that point.
smoking cessation, weight loss, exercise, pre-diabetes identification –
screening programs are fixed, inflexible , protocoled care, applied across a particular age group- safeguarding, frailty, VTE, dementia screening, hypertension, alcohol issues, obesity, domestic violence, smoking

case scenario of overweight person presents with orthopaedic problems, upon discharge do you speak to them about their weight? as an ED physician

case scenario of unwell child who has never been vaccinated – what will you do? How do you approach the subject with the parent, or do you even approach it at all?

case scenario of alcoholic patient with head injury – would you address the alcohol issue? (unit is 8 gm or 10 ml) 25 in whiskey, 10 in wine and 40 in spirigel
alcohol problems discussion
(having withdrawal symptoms when not drinking is being dependant on alcohol)
who should you be screening for problem drinking – selected presentations
how do you ask for alcohol intake?- use PAT scale – CAGE questions are useful in establish alcohol related problems.
important because intervention is helpful

PUBLIC HEALTH AND EMERGENCY MEDICINE
as doctors/physicians it is our ethical duty to reduce injury and illness, wherever we interact with patients.
we tend to have more interaction with the general public
you are more likely to see violence/injuries than the police – some studies show more than 3 times!
how can you help as doctors? injury survielance, mandatory reporting, better design, improve treatment, collate data and improve conditions – location of assault, date/time of assault, weapon, age
is anonymous,
crime rates went down because of data collected due to targeted policing
what are barriers to implementation? – police expectations, IT issues, governance, receptionist, leads
pitfalls – mission creep, fatigue, silos
conclusion? violent injury surveillance and control is effective in reducing violence. implementation can be challenging

QI (Quality Improvement)
audits are important but rarely work
why do they fail? – tick box exercise, temporary staff, lack of feedback, career advancement a priority rather than care advancement, lack of collective responsibility (if your rotation ends, the audit ends with you, no continuity)
has now become quality assurance rather than improvement. “maintaining/meeting set standards” rather than “improving the standards”
RCEM guide to QI is the QI bible.
do less, do it better
choose a standard to improve:is it important?, is it fundamental?, is it fixable?
talk to the stakeholders (nursing staff, frontline staff, triage, juniors, etc), ask them why this is not happening – how to improve conditions?
measure the standard
intervene to implement a change, and then re-measure after a suitable timeframe.
establish or convey a sense of crisis – reiterate how important/imperative this measurement is.
rapid cycle

CARDIOLOGY – ACS
definition of ACS
reiteration of importance of history – onset and character
repeat ecg, compare with previous
do not delay treatment waiting for biomarkers in “cardiac-sounding” chest pain.
consider bedside imaging if hemodynamic instability
escalate appropriately, consider involvement of tertiary care
dissection a differential? CT aorta stat (discussion about d dimer as useful in this scenario – some people say a negative d dimer rules out a dissection – research shows that is not the case)
management – analgesia+dual antiplatelet therapy, GP2B3AI, antihypertensives (b blockers) ACEI. statin, REGARDLESS OFWHETHER AN INTERVENTION TAKES PLACE LATER ON OR NOT, GIVE THE MEDICAL TREATMENT. if already on aspirin, 300 or 225 of aspirin either way doesn’t matter, 600 of clopidogrel and 80 of tigacrelor (not to use if warfarinized – MAKE SURE INR IS THERAPEUTIC)
immediate management – angio +/- PCI (for STEMI within window, ongoing symptoms, cariogenic shock, for NSTEMI – hemodynamic instability, ongoing schema or shock, IF REFRACTORY TO INITIAL MEDICAL THERAPY)
high risk/labile/recurrent schema – urgent angio
all others get routine angio
12 hours stemi – def PPCI, greater than 12 hours – if symptoms, PPCI, greater than 48 hours – no PPCI.
<30 mins door in door out in non pic centers. <60 mins door to wire crossing in PCI centre. and LBBB/RBBB considered equally. no o2 if >90 sats on RA.
consider CPAP, IF DISTRESS. iv amiodarone for AF, Look for hyperglycaemic states, MRA if CF.

if unable to decide if LBBB is new or old, compare to previous but if none available to compare, look at the patient. vast majority are not acute, unless they’re in cariogenic shock.

 

DIARRHOEA
definition
types
causes
symptoms
may be a symptom of sepsis – does not mean primary focus is gastrointestinal- particularly in the elderly
rotavirus most common in children – vaccine now available, rotarix at 8 and 12 weeks, seasonal
COD – dehydration/acidosis
use dioralyte instead of pure water for replacement. diluted juice.
norovirus and c.difficile has to be reported.
electrolyte disturbances – hypo/hypernatremia, acidosis, acidosis, hypoklemia (3-3.5: oral replacement or 20/1000 ml saline over 2-3 hours; 2.5-3: 40/litre over 4-6 hours; <2.5 or with ecg changes at any low level such as prolonged QTC, flat t waves at risk of arrhythmia; <1.5 will be paralysed, muscular weakness, apneoic. ECG-CARDIAC MONITOR-CONSIDER RESUS
discussion about hyponatremia and its management

 

PALPITATIONS
multiple cases discussed and shown, along with rhythm strips, interactive 1 hour session with responses from the audience tailoring the talk. VERY interesting.

FRCEM Intermediate (SAQ) – “Revisiting the recent past (recalling the nightmare!)”

  1. picture of a bruised foot. fallen off horse, foot stuck in stirrup and dragged upside down. now unable to weight bear. bruising evident on medial dorsal area and lateral plantar area of involved foot. what is the mechanism of injury? what is the injury?
  2. patient with small stab wound to epigastrium. X-ray (picture shown) shows air under diaphragm on right side. what is the finding on X-ray and what does it signify? what is the management plan for this condition? how will you investigate/comfirm diagnosis next?
  3. image of bilateral knees of a middle aged patient. presented with sudden swelling and painful left knee, which is shown as slightly swollen. cause? treatment/management?
  4. paeds patient, infant, barking cough every time they cough. sniffling viral like symptoms …diagnosis? management?
  5. anaesthetic machine shown with knobs for respiratory rate and tidal volume adjustment, rest rate set at 8/min. scenario given of patient with head injury, aside from other measures, what will you do to ventilator settings to help, and how will it help.
  6. picture of pneumothorax (right sided) shown. what are the 2 abnormalities in the radiograph? (i could only see the pneumothorax) management questions about where to insert the seldinger, and what common complication can happen and how will you avoid it (what measures will you take to ensure it doesn’t happen)
  7. elbow posterior dislocation image shown. how will you manage in ED (explain/summarise maneuver) and what nerve tends to be damaged and what will you look for on neurological examination. what x 2 steps will you do after reduction
  8. image of posterior dislocation of shoulder shown. radiological sign?
  9. young child, accidental ingestion of paracetamol syrup. asymptomatic. previous history of similar episode last year. what steps will you take? when will blood need to be drawn?
  10. wife presents to ED with injuries sustained from beating by husband. has minor children but are not currently living at home with her or husband and have not witnessed abuse. she self discharges and does not want to press charges. what steps do you need to take
  11. image of open mouth, what is the malampatti scoring?
  12. young male, fallen from 30 foot height, complaining of back pain. otherwise normal examination. what is the first reasonable investigation?
  13. head injury patient, subdural hematoma. gcs 13/15 initially, on revaluation, drops gcs to 10/15, what will be your next step in management? how will you proceed? if they initially are ventilating well, and then drop sats, how will you proceed further?
  14. transferring patient who is intubated and ventilated suddenly notice significant drop in sats, blood pressure OK, what is likely cause, how will you manage/proceed?
  15. sudden onset painful testicular swelling in young male – likely cause? management? what time frame? if not this, then what is the next likely cause
  16. young girl – dizziness and fainting spells. biochemistry shows hypoglycemia, borderline raised potassium, borderline low sodium. diagnosis? what investigation will you do?
  17. renal failure patient, sudden worsening. ecg shown, hyper acute t waves seen. diagnosis? management? mechanism of action of 1 drug that you will prescribe
  18. pregnancy 3rd trimester. abdominal trauma. abdominal pain, hypotension, diagnosis? management?
  19. middle aged female, found with suicide note and empty pill packets. low gcs. blood gas shows alkalosis, low co2, high bicarb. likely drug?
  20. paeds with sob, not eating, generally unwell but appears well, playing with toys, interacting, low sats but other jobs all normal no fever. cxr shown (normal looking?) ? diagnosis?
  21. elderly patient, hip fracture, fascia iliac block administered for pain relief. sudden dizziness, followed by cardiac arrest. cause? how will you manage? (dose and name of drug)
  22. how will you immobilize/pull femur on child with fracture femur? analgesia options?
  23. image of facial trauma during RTC – airway concerns? how will you manage complications/difficulty? what will you advise your colleagues to do or not do
  24. post vomiting, chest pain, car shown, findings? (subcutaneous emphysema)what 2 causes can be attributed to this condition? how will you investigate further to find out which cause this is
  25. ecg shown ? LBBB?
  26. ecg shown – VT – conscious patient with palpitations. shocks given x 3 not reverted, how will you manage further.
  27. epipen administered. what total dose in MG of adrenaline administered in single dose?
  28. seizure activity in epileptic patient, already on phenytoin. status epilepticus. diazemols/lorazepam 1 dose given. allergic to valproate. what is the next 2nd line drug to give?
  29. patient on warfarin, routine blood tests high INR of 8-9 no bleeding, recent antibiotics. what possible antibiotics would have been used? first step in management?
  30. female child from african country, returning from trip, feeling unwell, crying, not interacting. c/o ado pain etc. no fever, all obs normal. nurse noticed bloody discharge on underpants. likely diagnosis? who will you inform? how will you manage?
  31. hip pain, limping child, non traumatic? X-rays shown. what view is it? what is the diagnosis? what are x 2 common causes of hip pain without trauma in paediatric age group?
  32. renal colic clinical picture. analgesic of choice? investigation to confirm? complications?
  33. paracetamol overdose patient. what x2 investigations will you perform?
  34. elderly patient present with a fall. what bedside investigation can you do to rule out dehydration
  35. patient with ascites, fever, abdo pain. diagnosis? where will you put needle in for ascitic tap?
  36. patient with red eye shown (image) presents with sudden onset headache, vomiting. diagnosis? management? what topical drug will you administer in ED?
  37. elderly patient, agitated, needs cannula. what will you give to the patient? what will you tell the helping nurse to do?
  38. patient with chest pain. ecg shows inferior MI.
  39. IVDU. c/o back pain. tender lumbar region. diagnosis? investigation?
  40. question about intraosseous access
  41. young male with rectal bleeding and diarrhoea travelling from african/middle eastern country. cause? give non infectious/non inflammatory cause
  42. scenario is patient has ingested amyl nitrate. picture of patient’s wound site with swab on – showing bleeding, blood is ?darker color than usual? identify what the abnormality is, and how will you treat it
  43. high BMI (50) patient, unconscious/collapsed – what factors affect her airway and what makes it a difficult airway for her – what manoeuvres will you do to improve/mange these factors
  44. do not remember the question but size of cannula given and rate or time 1 litre of saline gets completely given through it

Interesting Observations on a mock OSCE Teaching Day

Hi all – so a few days back I had the unique opportunity to organize (OK who am I kidding? I helped to organise) a 1-day course for the FRCA OSCE exam in our deanery. We as the juniors of the department of anaesthetics/ITU/Theaters were called upon to help with various tasks: timekeeper for the different stations, be a patient for history taking, or be one of the relatives for counselling, be a mannequin for examinations, etc. I had a multitude of nominal tasks on the day, but what I found to be invaluable to me that day were a few observations that I made observing the various candidates as they filed through the different stations, and I list those observations here in no particular order to be taken as advice for all my colleagues who have OSCEs to take, bear these in mind:

– Be cognisant of time. As you walk up to the OSCE station, whether it gives you 30 seconds to read through an initial scenario or there is a piece of paper with questions written on it that you are expect to answer, get into the mental zone where you can mould yourself to give what is required of that particular station in the time provided. If there is one question that needs to be answered, you can be a bit relaxed, if there are 3 questions on the paper, make sure you are aware of the time you have to divide amongst them all to do justice to all. If the station requires an interaction with someone like a viva or a direct encounter, make sure you have a framework in mind, a mental checklist to check things off during the actual station so that you are not rambling on about your second point when there are 7 other things you need to be talking about.

–  When asked a question, don’t feel pressured to answer as soon as you sit down – take a breath, pause, ponder over the question for a few seconds, frame your answer for the next few, and then open your mouth to speak. Do not repeat the question back to the examiner in wonderment, as if puzzling it over, you may think you are buying time while you collect your thoughts, but it looks unprofessional. If you need time to answer, take it, but do not insult the examiners’ intelligence by repeating the question back word for word. It is a waste of time.

– When asked a question, avoid using pronouns like ‘you’ as a general term. “If you are on the floor for a long time, your creatinine kinase levels may rise.” While correct, it looks like you are addressing the examiner, whereas a more professional way to answer would be “Patients lying on the floor for extended periods of time may have elevated levels of creatinine kinase.”

– Following on from the previous point – when describing the anatomical location of anything, or a function, it is OK to use your hands to express yourself, but do not gesture towards your own body as a descriptor for your answer. In answer to the question Where can an IO needle be inserted? you may think it is the right answer to point to your sternum, your humerus or your tibial tuberosity, but it won’t score you any points. Also please practise certain expressions or gestures, gesturing towards your crotch for instance when talking about urinary catheterisation is inappropriate. And for goodness sake, it is even worse to point these things out on the examiners body.

– Use proper terminology, use buzzwords if you know them (we all know them) and specific things carry specific marks so make sure you attend some sort of course at least once in your life for OSCE practise so that you know what the examiner is looking for in a particular station when they ask you a particular question. Also, examiners know when you are beating about the bush and not getting to the point – so don’t waste their time (and yours), admit you do not know, and move on.

– Having done poorly in a previous station has no bearing on how you can or should perform in the next one – so do not let anything bother you. Yes, you may well have failed the previous station, but if you continue to mull over it or let it get to you, you may ruin your chances of passing the next one as well. Once you step out of one station, close that chapter, and open the next one with a clean slate.

–  Do not try to impress with big words and fancy terms – be simple, logical and just answer to the best of your knowledge. They are there to test your knowledge and see how good you are with using that knowledge. They are not there to ask for your hand in marriage.

–  If there is a written station, please write clearly. In our current professional examination climate, where usually there is a tick box or a fill-in-the-correct-circle type answer sheets, we forget how to answer the short answer type questions. Make sure it is legible. Your right answer is useless if no one can decipher it.

–  Read up on the simple things (in case of our anaesthetics colleagues, anatomy and physiology, undoubtedly – aside from the usual physics etc) – understand the concept behind why something is done or not done, and it will make it easier for you in these exams.

–  Study. I don’t know why it is so under-rated, that OSCE exams are interaction based and so I just don’t need to read up on how to take a history or do a pre-op assessment or perform a physical examination or test the cranial nerves – we do it everyday, and we get into a comfortable zone – but the exam might need for us to brush up on those skills and make sure we are not missing out on anything. MOST candidates missed an important part of the history taking station, as well as the counselling station – points were docked, valuable points, and for some that can mean the difference between passing and failing.